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HomeMy WebLinkAboutPersonal Impressions - Insurance CertificateDECEMBER 11, 2017 CITY OF GILROY 7301 HANNA ST GILROY CA 95020 -6129 IN REPLY REFER TO: CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION WITHDRAWAL NOTICE ------------------------ - - - - -- RE: CERTIFICATE DATED NOVEMBER 10, 2017 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON NOVEMBER 27, 2017. THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. EMPLOYER: PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY, CA 95020 POLICY 9085403 -17 CUSTOMER SERVICE REPRESENTATIVE CUSTOMER SERVICE CENTER (888) 782 -8338 5860 Owens Dr Pleasanton, CA 94588 -3900 Mailing Address: P.O. Box 8192 - Pleasanton, CA 94588 -9682 SCIF 19102 Ac ®RD® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 7/21/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME. Erin HOSler IPA HONE (831)233 -7199 F0� o (866)835 -6983 The Liberty Company Insurance Brokers EDpRIESSehosler @libertycompany.com 615 San Benito Street, #101 INSURERS AFFORDING COVERAGE NAIC # EACH OCCURRENCE INSURER A•Securit National Ins Co 19879 Hollister CA 95023 INSURED INSURER 6: MED EXP (Any one person) INSURER C Personal Impressions INSURER D: $ 1,000,000 331 El Cerrito Way INSURER E : $ 2,000,000 PRODUCTS - COMP /OP AGG INSURER F: Gilroy CA 95020 COVERAGES CERTIFICATE NUMBER:2017 -18 GL REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM /DDIYYYY POLICY EXP MMIDDNYYY LIMITS A R COMMERCIAL GENERAL UABIUTY CLAIMS -MADE 7x] OCCUR R Y NA105295005 4/27/2017 4/27/2018 EACH OCCURRENCE $ i'000,000 RENTED DAMAGE TO Ea occurrence) PREMISES $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL BADVINJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER X POLICY E PRO ❑ LOC JECT OTHER GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 1,660,660 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ -DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) H yes, describe under DESCRIPTION OF OPERATIONS below NIA PER OTH- STATUTE I I ER E L EACH ACCIDENT $ E L DISEASE - EA EMPLOYE $ E L DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) RE: All California Operations The City of Gilroy, its officers and employees are additional insured per the attached 49 -0108 07 11. totK 111-II;A I t MULUtK City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 ACORD 25 (2014/01) INS025 (701401) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE rin Hosler /SHERRI ©1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Policy Number: NA105295005 Endorsement Effective: 7/21/201712:01 a.m. Named Insured Countersigned Bvw/lxtv TIMOTHY KEVIN COLLINS PERSONAL ]IMPRESSIONS SCHEDULE Name of Person or Organization: THE CITY OF GILROY, ITS OFFICERS AND EMPLOYEES 7351 ROSANNA STREET, GILROY CA 95020 Location: VARIOUS LOCATIONS THROUGHOUT THE STATE OF CA (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) A. Section II — Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured B. With respect to the insurance afforded to these additional insureds, the following exclusion is added 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the site of the covered operations has been completed, or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project C. The words "you" and "your' refer to the Named Insured shown in the Declarations D. "Your work" means work or operations performed by you or on your behalf, and materials, parts or equipment furnished in connection with such work or operations Pnmary Wordme If required by written contract or agreement Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self - insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it 49 -0108 0711 May Include Copyrighted Material of Insurance Services Offices, Inc Page 1 of 1 Used with permission Waiver of Subrogation If required by written contract or agreement We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for rnjury or damage arising out of "your work" done under a contract with that person or orgaruzation Page 2 of 2 © ISO Properties, Inc, 2000 49 -0108 07 11 °® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 6/29/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Erin Hosler PHONE (831) 233 -7199 NC No: (866) 835 -6983 The Liberty Company Insurance Brokers ADDRESS :ehosler @libertycompany.com 615 San Benito Street, #101 INSURERS AFFORDING COVERAGE NAIC # EACH OCCURRENCE INSURER A:Security National Ins Co 19879 Hollister CA 95023 INSURED INSURER B: MED EXP (Any one person) INSURER C: Personal Impressions INSURER D: $ 1,000,000 331 E1 Cerrito Way INSURER E: GENERAL AGGREGATE $ 2,000,000 INSURER F: PRODUCTS - COMP /OPAGG Gilroy CA 95020 COVERAGES CERTIFICATE NUMBER:2016 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR X NA105295004 4/27/2016 4/27/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO F7 LOC JECT OTHER: GENERAL AGGREGATE $ 2,000,000 X PRODUCTS - COMP /OPAGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ --tMIDT AGGREGATE _ $ I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR /PARTNER/EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A I I PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: All California Operations The City of Gilroy, its officers and employees are additional insured per the attached 49 -0108 07 11. City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 ACORD 25 (2014101) INS025 r9014n1I L:ANL:tLLA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE rin Hosler /EHOSLE- bCJ��.. �---�� C 1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JUNE 23, 2016 CITY OF GILROY 7351 ROSANNA ST GILROY CA 95020 -6141 IN REPLY REFER T0: CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION WITHDRAWAL NOTICE ------------------------ - - - - -- RE: CERTIFICATE DATED NOVEMBER 1, 2015 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON JUNE 22, 2016. THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. EMPLOYER: PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY, CA 95020 POLICY 9085403 -15 CUSTOMER SERVICES UNIT SAN FRANCISCO DISTRICT OFFICE (925) 523 -5100 5860 Owens Dr Pleasanton, CA 94588 -3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588 -9682 SCIF 19102 JUNE 6, 2016 CITY OF GILROY 7351 ROSANNA ST GILROY CA 95020 -6141 IN REPLY REFER T0: CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION WITHDRAWAL NOTICE ------------------------ - - - - -- RE: CERTIFICATE DATED NOVEMBER 1, 2015 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON JUNE 1, 2016. THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. EMPLOYER: PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY, CA 95020 POLICY 9085403 -15 CUSTOMER SERVICES UNIT SAN FRANCISCO DISTRICT OFFICE (925) 523 -5100 5860 Owens Dr Pleasanton, CA 94588 -3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588 -9682 SCIF 19102 IN REPLY REFER T0: JUNE 1, 2016 CITY OF GILROY 7351 ROSANNA ST GILROY CA 95020 -6141 CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION NOTICE ------------- - - - - -- RE: CERTIFICATE DATED NOVEMBER 1, 2015 THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW WILL BE CANCELLED EFFECTIVE JUNE 17, 2016 AT 12 :01 A.M. IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE EMPLOYER NAMED BELOW EMPLOYER: PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY, CA 95020 POLICY 9085403 -15 CUSTOMER SERVICES UNIT SAN FRANCISCO DISTRICT OFFICE (925) 523 -5100 5860 Owens Dr Pleasanton, CA 94588 -3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588 -9682 SCIF 19102 APRIL 28, 2016 CITY OF GILROY 7351 ROSANNA ST GILROY CA 95020 -6141 IN REPLY REFER TO: CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ---------------------- CANCELLATION WITHDRAWAL NOTICE ------------------------ - - - - -- RE: CERTIFICATE DATED NOVEMBER 1, 2015 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON APRIL 20, 2016. THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. EMPLOYER.: PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY, CA 95020 POLICY 9085403 -1.5 CUSTOMER SERVICES UNIT SAN FRANCISCO DISTRICT OFFICE (925) 523 -5100 5860 Owens Dr Pleasanton, CA 94588 -3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588 -9682 SCIF 19102 CERTHOLDER COPY P.O. BOX 8192, PLEASANTON, CA 94588 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 11 -01 -2014 CITY OF GILROY NA 7351 ROSANNA ST GILROY CA 95020 -6141 GROUP: POLICY NUMBER: 9085403 - 2014 -2 CERTIFICATE ID: 3 CERTIFICATE EXPIRES: 11-01 -2015 11-01- 2014/11 -01 -2015 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an 'insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. EMPLOYER COLLINS, TIMOTHY K. DBA: PERSONAL IMPRESSIONS 331 EL CERRITO WAY GILROY CA 95020 M0408 (REV.7 -2014) PRINTED : 10 -18 -2014 M